Jen Roux, Neelke Doorn, Saba Hinrichs-Krapels, Samantha Copeland
Current approaches to health system resilience tend to prioritize system-level outcomes (e.g. functionality) while overlooking key underlying social processes, contexts, and power-laden interactions through which resilience is produced. When community resilience is subsumed under health system resilience, without attending to distinct contextual factors, it can lead to fragmented approaches or maladaptive outcomes that misalign with the resilience of communities. Therefore, resilience approaches need to include additional methods that incorporate analyses of power structures and context. We propose intersectionality theory as a methodological lens to investigate the underlying social processes and power dynamics that shape community resilience and health system resilience interactions. An intersectionality approach prompts researchers to distinguish how resilience capacity is derived through the involvement of community actors, their unique intersecting social identities and their lived experiences. Including an intersectional lens in resilience approaches provides researchers with the tools to identify points of practical constraints that arise at the intersection of communities and health systems, with particular attention on the burdens that are placed on community actors.
{"title":"Justice at the interface: advancing community and health system resilience through intersectionality theory.","authors":"Jen Roux, Neelke Doorn, Saba Hinrichs-Krapels, Samantha Copeland","doi":"10.1093/heapol/czag005","DOIUrl":"https://doi.org/10.1093/heapol/czag005","url":null,"abstract":"<p><p>Current approaches to health system resilience tend to prioritize system-level outcomes (e.g. functionality) while overlooking key underlying social processes, contexts, and power-laden interactions through which resilience is produced. When community resilience is subsumed under health system resilience, without attending to distinct contextual factors, it can lead to fragmented approaches or maladaptive outcomes that misalign with the resilience of communities. Therefore, resilience approaches need to include additional methods that incorporate analyses of power structures and context. We propose intersectionality theory as a methodological lens to investigate the underlying social processes and power dynamics that shape community resilience and health system resilience interactions. An intersectionality approach prompts researchers to distinguish how resilience capacity is derived through the involvement of community actors, their unique intersecting social identities and their lived experiences. Including an intersectional lens in resilience approaches provides researchers with the tools to identify points of practical constraints that arise at the intersection of communities and health systems, with particular attention on the burdens that are placed on community actors.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2026-01-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145997958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Stefan Reinders, Magaly M Blas, Angela Alva, Luis Huicho, Carine Ronsmans, Isabelle L Lange
In rural Indigenous communities in the Peruvian Amazon, access to quality care is difficult, home births are frequent, and neonatal mortality remains high. Peru has a large cadre of Community health workers (CHW), yet their potential is not harnessed. A recent outcome evaluation of a community-based intervention showed improvements in essential newborn care (ENC) for home births and small increases in facility births. To explain these findings, elucidate the pathways of change, and derive policy recommendations, we conducted a mixed-methods process evaluation. Implementation strength, mechanisms of change, and influence of contextual factors were assessed using data collected from women, CHW, traditional birth attendants (TBA), supervisors, and community members. We calculated programme coverage and intervention exposure and explored experiences, perceptions, and birth stories through interviews, focus group discussions, and participant observation using content analysis. Triangulated findings were narratively synthesized and contrasted to hypothesized intervention mechanisms. The programme achieved high coverage of well-trained CHW and TBA supported by intensive supervision. Multiple pathways of change were identified: Trained TBA as main providers of home-based birth care implementing ENC; CHW home visits sensitizing women through educational videos and provision of delivery kits, albeit with less reach and counselling than expected; and supervisor-led, women-only educational meetings. Some CHW proactively facilitated access to facility care, while promotion alone to increase demand appeared insufficient. Pathways of change identified support a causal link between the intervention and observed behaviour changes in the outcome evaluation. Our findings demonstrate the potential of community-based approaches involving CHW and TBA which should be given greater importance in national health policy. To improve impact and sustainability of the Peruvian CHW programme, we provide several context-specific recommendations.
{"title":"Pathways of change for essential newborn care practices and health care seeking: a process evaluation of Mamás del Río, a community-based, maternal and neonatal health intervention in the Peruvian Amazon.","authors":"Stefan Reinders, Magaly M Blas, Angela Alva, Luis Huicho, Carine Ronsmans, Isabelle L Lange","doi":"10.1093/heapol/czag004","DOIUrl":"https://doi.org/10.1093/heapol/czag004","url":null,"abstract":"<p><p>In rural Indigenous communities in the Peruvian Amazon, access to quality care is difficult, home births are frequent, and neonatal mortality remains high. Peru has a large cadre of Community health workers (CHW), yet their potential is not harnessed. A recent outcome evaluation of a community-based intervention showed improvements in essential newborn care (ENC) for home births and small increases in facility births. To explain these findings, elucidate the pathways of change, and derive policy recommendations, we conducted a mixed-methods process evaluation. Implementation strength, mechanisms of change, and influence of contextual factors were assessed using data collected from women, CHW, traditional birth attendants (TBA), supervisors, and community members. We calculated programme coverage and intervention exposure and explored experiences, perceptions, and birth stories through interviews, focus group discussions, and participant observation using content analysis. Triangulated findings were narratively synthesized and contrasted to hypothesized intervention mechanisms. The programme achieved high coverage of well-trained CHW and TBA supported by intensive supervision. Multiple pathways of change were identified: Trained TBA as main providers of home-based birth care implementing ENC; CHW home visits sensitizing women through educational videos and provision of delivery kits, albeit with less reach and counselling than expected; and supervisor-led, women-only educational meetings. Some CHW proactively facilitated access to facility care, while promotion alone to increase demand appeared insufficient. Pathways of change identified support a causal link between the intervention and observed behaviour changes in the outcome evaluation. Our findings demonstrate the potential of community-based approaches involving CHW and TBA which should be given greater importance in national health policy. To improve impact and sustainability of the Peruvian CHW programme, we provide several context-specific recommendations.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2026-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145988926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dominic Dormenyo Gadeka, Genevieve Cecilia Aryeetey, Helen Bour, Henry Okudzeto, Patrick Addo, Noemia Teixeira de Siqueira Filha, Bassey Ebenso, Helen Elsey, Irene A Agyepong
Primary healthcare provider networks (PHCPNs) are increasingly recognized as promising strategies to effectively strengthen health systems in low- and middle-income countries (LMICs). However, there is limited information on the influence PHCPNs may have on the process and clinical outcomes of health services. This study sought to answer the questions: what is the extent, range and nature of research on PHCPNs in LMICs, what are the types of PHCPNs described, and what are the processes e.g. access to care, coverage of health services, quality of care and services, safety of care and the clinical care outcomes of PHCPNs reported in the published literature? We report on a systematic mixed-methods review on PHCPNs as a strategy to strengthen health systems in LMICs following the PRISMA guidelines. The quality of the included studies was assessed using the ROBINS-I and Mixed Methods Appraisal tools, while a narrative synthesis was employed to describe the results. Fifteen primary studies were found eligible for the review. From the included papers, eight types of PHCPNs were identified across various contexts and countries. We found that the PHCPNs primarily focus on maternal, newborn, and child health outcomes. The study reveals that: (1) PHCPNs contribute to improvements in the process outcomes of health services by enhancing access to care, coverage of health services, quality of care and services, and safety of care, and (2) they support improvements in clinical outcomes by helping to reduce maternal, neonatal, and perinatal mortalities and stillbirths. This body of literature we reviewed suggests that PHCPNs make a difference in the process and clinical outcomes of health services in LMICs. This review serves as both a mapping and clarification exercise to promote the adoption of PHCPNs and as a foundation for further research, especially in areas of health services beyond maternal, newborn, and child health.
{"title":"Primary health care networks and impacts in LMICs: A systematic review.","authors":"Dominic Dormenyo Gadeka, Genevieve Cecilia Aryeetey, Helen Bour, Henry Okudzeto, Patrick Addo, Noemia Teixeira de Siqueira Filha, Bassey Ebenso, Helen Elsey, Irene A Agyepong","doi":"10.1093/heapol/czag003","DOIUrl":"https://doi.org/10.1093/heapol/czag003","url":null,"abstract":"<p><p>Primary healthcare provider networks (PHCPNs) are increasingly recognized as promising strategies to effectively strengthen health systems in low- and middle-income countries (LMICs). However, there is limited information on the influence PHCPNs may have on the process and clinical outcomes of health services. This study sought to answer the questions: what is the extent, range and nature of research on PHCPNs in LMICs, what are the types of PHCPNs described, and what are the processes e.g. access to care, coverage of health services, quality of care and services, safety of care and the clinical care outcomes of PHCPNs reported in the published literature? We report on a systematic mixed-methods review on PHCPNs as a strategy to strengthen health systems in LMICs following the PRISMA guidelines. The quality of the included studies was assessed using the ROBINS-I and Mixed Methods Appraisal tools, while a narrative synthesis was employed to describe the results. Fifteen primary studies were found eligible for the review. From the included papers, eight types of PHCPNs were identified across various contexts and countries. We found that the PHCPNs primarily focus on maternal, newborn, and child health outcomes. The study reveals that: (1) PHCPNs contribute to improvements in the process outcomes of health services by enhancing access to care, coverage of health services, quality of care and services, and safety of care, and (2) they support improvements in clinical outcomes by helping to reduce maternal, neonatal, and perinatal mortalities and stillbirths. This body of literature we reviewed suggests that PHCPNs make a difference in the process and clinical outcomes of health services in LMICs. This review serves as both a mapping and clarification exercise to promote the adoption of PHCPNs and as a foundation for further research, especially in areas of health services beyond maternal, newborn, and child health.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145988918","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ankita Meghani, Shreya Hariyani, Prabhjeet Singh, Sara Bennett
India's second wave of the COVID-19 pandemic in April-June 2021 involved an explosion of case numbers, with devastating consequences for the country's already strained health systems. This case study examines the private health market response to the pandemic in Uttar Pradesh, India's most populous state. We analyzed 203 news articles to understand both the experiences of private providers and patients in response to government policies being implemented in the state. This analysis informed our interviews with 20 state-level officials, district-level key informants, and formal and informal private-for-profit providers across 3 districts. We found that private sector hospitals were rapidly engaged to manage a surge in new infections and severe cases, but private bed capacity quickly filled, causing patients to be turned away. Informal private providers played a vital role in rural areas, serving as round-the-clock care sources. However, the news media reported inadequate medical care from such providers leading to COVID-19-related deaths. Access to reliable information on COVID-19 was challenging and social media became a platform for citizens and providers to share information about available resources, treatment, and COVID-19 management. However, misinformation also spread. While the government attempted to counter misinformation and regulate private hospitals, challenges persisted in providing and accessing accurate information. Oxygen and drug supply challenges also emerged, with private hospitals requiring patients to arrange oxygen due to scarcity. To address this and rising costs of care, the government issued price caps, monitored overcharging, and regulated drug and oxygen distribution. Government schemes also attempted to provide insurance for both public and private health workers, however, awareness and implementation of such schemes were inadequate. Policymakers should develop mechanisms to engage, or where relevant, integrate all private-for profit providers onto a common platform, strengthen referral linkages amongst them, and support communities of practice to increase awareness of government health policies and improve the implementation of government schemes. All together, these measures would help facilitate equitable access to care and help manage current health needs and future health emergencies.
{"title":"Health systems resilience and private-for-profit sector engagement: lessons from the second COVID-19 wave in Uttar Pradesh, India.","authors":"Ankita Meghani, Shreya Hariyani, Prabhjeet Singh, Sara Bennett","doi":"10.1093/heapol/czag001","DOIUrl":"https://doi.org/10.1093/heapol/czag001","url":null,"abstract":"<p><p>India's second wave of the COVID-19 pandemic in April-June 2021 involved an explosion of case numbers, with devastating consequences for the country's already strained health systems. This case study examines the private health market response to the pandemic in Uttar Pradesh, India's most populous state. We analyzed 203 news articles to understand both the experiences of private providers and patients in response to government policies being implemented in the state. This analysis informed our interviews with 20 state-level officials, district-level key informants, and formal and informal private-for-profit providers across 3 districts. We found that private sector hospitals were rapidly engaged to manage a surge in new infections and severe cases, but private bed capacity quickly filled, causing patients to be turned away. Informal private providers played a vital role in rural areas, serving as round-the-clock care sources. However, the news media reported inadequate medical care from such providers leading to COVID-19-related deaths. Access to reliable information on COVID-19 was challenging and social media became a platform for citizens and providers to share information about available resources, treatment, and COVID-19 management. However, misinformation also spread. While the government attempted to counter misinformation and regulate private hospitals, challenges persisted in providing and accessing accurate information. Oxygen and drug supply challenges also emerged, with private hospitals requiring patients to arrange oxygen due to scarcity. To address this and rising costs of care, the government issued price caps, monitored overcharging, and regulated drug and oxygen distribution. Government schemes also attempted to provide insurance for both public and private health workers, however, awareness and implementation of such schemes were inadequate. Policymakers should develop mechanisms to engage, or where relevant, integrate all private-for profit providers onto a common platform, strengthen referral linkages amongst them, and support communities of practice to increase awareness of government health policies and improve the implementation of government schemes. All together, these measures would help facilitate equitable access to care and help manage current health needs and future health emergencies.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2026-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145959257","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Community pharmacies are increasingly recognised as access points for public health interventions (PHIs) such as vaccination, family planning services and disease screening. In Kenya, evidence suggests feasibility of pharmacy delivered PHIs, however, the uptake remains inconsistent. This is partly attributed to poor program design without taking pharmacy providers preferences into consideration. We employed a discrete choice experiment (DCE) to investigate community pharmacists preferences for attributes of PHIs delivered in community pharmacies in Kenya. We constructed a Bayesian efficient design and conducted a DCE survey among 663 community pharmacy providers in Makueni, Nairobi and Kisumu counties in Kenya from January 2025 to March 2025. Panel multinomial mixed logit, generalised multinomial logit and latent class models were used in the analysis. We also estimated willingness to pay (WTP) and willingness to accept (WTA) estimates using cost and profit margins as the monetary estimates respectively. We found that community pharmacists were willing to offer PHIs with a low preference for opting out (β=-3.5723, P<0.01). Preferences for PHIs significantly increased with higher profit margins (β=0.028, P<0.01) and decreased with higher cost of equipment (β= -0.00023, P<0.01). There were higher preferences for PHIs that require moderate training (β=0.266, P<0.01) and extensive training (β=0.141, P<0.05) compared to no additional training; and lower preferences for PHIs with complex interventions compared to simple interventions (β=-0.323, P<0.01). The WTP estimates showed that providers were willing to pay Khs. 11,738 (USD 90) for moderate training and Kshs. 7,327 (USD 56) for extensive training. Moreover, the WTA estimates showed that providers were willing to accept a 10.9% increase in profit margin in order to deliver complex interventions. In addition to this, a three-class latent class model revealed preference heterogeneity among the respondents. These findings can be used to inform the design of PHIs to enhance uptake and acceptability among providers.
社区药房越来越被认为是公共卫生干预措施(PHIs)的接入点,例如疫苗接种、计划生育服务和疾病筛查。在肯尼亚,有证据表明药房提供公共卫生信息的可行性,然而,采用情况仍然不一致。这部分是由于糟糕的程序设计没有考虑到药房提供者的偏好。我们采用离散选择实验(DCE)来调查社区药剂师对肯尼亚社区药房提供的公共卫生信息属性的偏好。我们构建了贝叶斯有效设计,并于2025年1月至2025年3月对肯尼亚Makueni、Nairobi和Kisumu县的663家社区药房提供者进行了DCE调查。分析中使用了面板多项混合logit、广义多项logit和潜在类模型。我们还分别使用成本和利润率作为货币估计来估计支付意愿(WTP)和接受意愿(WTA)估计。我们发现,社区药剂师愿意提供公共卫生信息,选择退出的偏好较低(β=-3.5723, P
{"title":"Identifying Community Pharmacists Preferences for Attributes of Public Health Interventions in Kenya: A Discrete Choice Experiment.","authors":"Audrey Mumbi, Gilbert Abotisem Abiiro, Jacob Kazungu, Jacinta Nzinga, Edwine Barasa","doi":"10.1093/heapol/czag002","DOIUrl":"https://doi.org/10.1093/heapol/czag002","url":null,"abstract":"<p><p>Community pharmacies are increasingly recognised as access points for public health interventions (PHIs) such as vaccination, family planning services and disease screening. In Kenya, evidence suggests feasibility of pharmacy delivered PHIs, however, the uptake remains inconsistent. This is partly attributed to poor program design without taking pharmacy providers preferences into consideration. We employed a discrete choice experiment (DCE) to investigate community pharmacists preferences for attributes of PHIs delivered in community pharmacies in Kenya. We constructed a Bayesian efficient design and conducted a DCE survey among 663 community pharmacy providers in Makueni, Nairobi and Kisumu counties in Kenya from January 2025 to March 2025. Panel multinomial mixed logit, generalised multinomial logit and latent class models were used in the analysis. We also estimated willingness to pay (WTP) and willingness to accept (WTA) estimates using cost and profit margins as the monetary estimates respectively. We found that community pharmacists were willing to offer PHIs with a low preference for opting out (β=-3.5723, P<0.01). Preferences for PHIs significantly increased with higher profit margins (β=0.028, P<0.01) and decreased with higher cost of equipment (β= -0.00023, P<0.01). There were higher preferences for PHIs that require moderate training (β=0.266, P<0.01) and extensive training (β=0.141, P<0.05) compared to no additional training; and lower preferences for PHIs with complex interventions compared to simple interventions (β=-0.323, P<0.01). The WTP estimates showed that providers were willing to pay Khs. 11,738 (USD 90) for moderate training and Kshs. 7,327 (USD 56) for extensive training. Moreover, the WTA estimates showed that providers were willing to accept a 10.9% increase in profit margin in order to deliver complex interventions. In addition to this, a three-class latent class model revealed preference heterogeneity among the respondents. These findings can be used to inform the design of PHIs to enhance uptake and acceptability among providers.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2026-01-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145959224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Inaê Valério, Isabelle Uny, Alejandra Burela, Marina Piazza, Mark Petticrew, Niamh Fitzgerald, Zila M Sanchez
Implementing evidence-based alcohol policies can reduce the negative impact of alcohol consumption on public health. However, Brazil has permissive alcohol policies and weakly adheres to World Health Organization's recommendations as the 'best buys'. To explore stakeholders' perceptions of alcohol policy needs and barriers in Brazil, we conducted semi-structured interviews with 31 stakeholders, including 15 from civil society and 16 policymakers. Civil society participants included non-governmental organization leaders addressing alcohol-related issues, while policymakers comprised civil servants and politicians experienced in alcohol-related harms. Interviews were transcribed verbatim and thematically analyzed using a deductive approach guided by research questions and an inductive approach to identify emergent themes. Most participants supported World Health Organization-recommended 'best buy' policies regulating alcohol's marketing. However, agreement on price and availability control was not unanimous. All participants acknowledged significant political barriers to adopting these policies, including intentional delays in parliamentary voting, industry lobbying, and arguments about infringing on rights such as freedom. Facing obstacles to advancing population-level policies, stakeholders often shifted their focus to individual-level interventions, such as education and treatment. While these were recognized as less effective, educational efforts were highlighted for raising public awareness of alcohol's harms and changing normative beliefs. Participants noted the lack of a formal coalition to reduce alcohol-related harm, despite its perceived necessity. Overall, stakeholders supported population-level alcohol policies but were pessimistic about their implementation due to political barriers. Many, particularly from civil society, emphasized small-scale, targeted interventions as a more feasible alternative to address alcohol-related harm in Brazil.
实施循证饮酒政策可以减少酒精消费对公共卫生的负面影响。然而,巴西的酒精政策是宽松的,并且很少遵守世界卫生组织的建议,认为这是“最划算的”。为了探讨利益相关者对巴西酒精政策需求和障碍的看法,我们对31名利益相关者进行了半结构化访谈,其中15名来自民间社会,16名来自政策制定者。民间社会的参与者包括处理与酒精有关问题的非政府组织领导人,而决策者则包括经历过与酒精有关危害的公务员和政治家。访谈被逐字记录下来,并使用由研究问题和归纳方法指导的演绎方法对主题进行分析,以确定紧急主题。大多数与会者支持世界卫生组织(World Health organization)推荐的监管酒类营销的“最划算”政策。然而,在价格和供应控制方面的协议并不是一致的。所有与会者都承认,实施这些政策存在重大的政治障碍,包括故意拖延议会投票、行业游说以及有关侵犯自由等权利的争论。面对推进人口层面政策的障碍,利益攸关方往往将重点转向个人层面的干预措施,如教育和治疗。虽然这些措施被认为效果较差,但强调了教育工作,以提高公众对酒精危害的认识,并改变规范观念。与会者指出,尽管认为有必要成立一个正式的联盟来减少与酒精有关的危害,但却缺乏这个联盟。总体而言,利益攸关方支持人口层面的酒精政策,但由于政治障碍,对其实施持悲观态度。许多人,特别是民间社会的许多人强调,小规模、有针对性的干预是解决巴西与酒精有关的危害的更可行的替代办法。
{"title":"Untangling the complex web of alcohol policy needs and potential solutions in Brazil: evidence from civil society and political stakeholders.","authors":"Inaê Valério, Isabelle Uny, Alejandra Burela, Marina Piazza, Mark Petticrew, Niamh Fitzgerald, Zila M Sanchez","doi":"10.1093/heapol/czaf104","DOIUrl":"https://doi.org/10.1093/heapol/czaf104","url":null,"abstract":"<p><p>Implementing evidence-based alcohol policies can reduce the negative impact of alcohol consumption on public health. However, Brazil has permissive alcohol policies and weakly adheres to World Health Organization's recommendations as the 'best buys'. To explore stakeholders' perceptions of alcohol policy needs and barriers in Brazil, we conducted semi-structured interviews with 31 stakeholders, including 15 from civil society and 16 policymakers. Civil society participants included non-governmental organization leaders addressing alcohol-related issues, while policymakers comprised civil servants and politicians experienced in alcohol-related harms. Interviews were transcribed verbatim and thematically analyzed using a deductive approach guided by research questions and an inductive approach to identify emergent themes. Most participants supported World Health Organization-recommended 'best buy' policies regulating alcohol's marketing. However, agreement on price and availability control was not unanimous. All participants acknowledged significant political barriers to adopting these policies, including intentional delays in parliamentary voting, industry lobbying, and arguments about infringing on rights such as freedom. Facing obstacles to advancing population-level policies, stakeholders often shifted their focus to individual-level interventions, such as education and treatment. While these were recognized as less effective, educational efforts were highlighted for raising public awareness of alcohol's harms and changing normative beliefs. Participants noted the lack of a formal coalition to reduce alcohol-related harm, despite its perceived necessity. Overall, stakeholders supported population-level alcohol policies but were pessimistic about their implementation due to political barriers. Many, particularly from civil society, emphasized small-scale, targeted interventions as a more feasible alternative to address alcohol-related harm in Brazil.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2025-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145774386","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jacinta Nzinga, Easter Olwanda, Kennedy Opondo, Hillary Kimutai, Jan Cooper, Brian Arwah, Benjamin Tsofa, Edwine Barasa, Kevin Croke
The Maternal and Newborn Health (MNH) Service Delivery Redesign (SDR) in Kakamega County, Kenya, represents the country's first system-level reorganization of MNH services. The reform aimed to improve care quality and reduce mortality by centralizing delivery care at designated hubs. Using a political economy lens, we examined how ideology, political dynamics, and institutional structures shaped the agenda-setting, adoption, implementation, and sustainability of SDR. We drew on data from document reviews, stakeholder analysis, semi-structured interviews, and non-participant observation to assess the structural, contextual, and institutional factors influencing the reform. Ambiguity around SDR's purpose contributed to the community's uncertain engagement characterized by neither full endorsement nor resistance, highlighting the need for clearer communication and participation to build ownership. The interaction between formal institutions (county health governance and partnership frameworks) and informal norms (trust, shared interpretation, and relational coordination) created early momentum for implementation, particularly among health system actors. However, limited financial capacity and unclear alignment with national policy priorities undermined progress and long-term viability. Kakamega's experience demonstrates how political incentives, devolved autonomy, and local institutional context jointly shape reform outcomes. Achieving successful implementation of system level reforms requires integrating local political leadership, strengthening community engagement, aligning with evolving national policies, and securing predictable financing. This study provides practical lessons for future MNH and system-level reforms in Kenya and similar decentralized, resource-constrained settings. Lessons include the importance of balancing formal and informal institutions to ensure both political feasibility and enduring impact.
{"title":"Power, Interests, and Maternal Health Care: A Political Economy Analysis of Service Delivery Redesign in Kenya.","authors":"Jacinta Nzinga, Easter Olwanda, Kennedy Opondo, Hillary Kimutai, Jan Cooper, Brian Arwah, Benjamin Tsofa, Edwine Barasa, Kevin Croke","doi":"10.1093/heapol/czaf111","DOIUrl":"https://doi.org/10.1093/heapol/czaf111","url":null,"abstract":"<p><p>The Maternal and Newborn Health (MNH) Service Delivery Redesign (SDR) in Kakamega County, Kenya, represents the country's first system-level reorganization of MNH services. The reform aimed to improve care quality and reduce mortality by centralizing delivery care at designated hubs. Using a political economy lens, we examined how ideology, political dynamics, and institutional structures shaped the agenda-setting, adoption, implementation, and sustainability of SDR. We drew on data from document reviews, stakeholder analysis, semi-structured interviews, and non-participant observation to assess the structural, contextual, and institutional factors influencing the reform. Ambiguity around SDR's purpose contributed to the community's uncertain engagement characterized by neither full endorsement nor resistance, highlighting the need for clearer communication and participation to build ownership. The interaction between formal institutions (county health governance and partnership frameworks) and informal norms (trust, shared interpretation, and relational coordination) created early momentum for implementation, particularly among health system actors. However, limited financial capacity and unclear alignment with national policy priorities undermined progress and long-term viability. Kakamega's experience demonstrates how political incentives, devolved autonomy, and local institutional context jointly shape reform outcomes. Achieving successful implementation of system level reforms requires integrating local political leadership, strengthening community engagement, aligning with evolving national policies, and securing predictable financing. This study provides practical lessons for future MNH and system-level reforms in Kenya and similar decentralized, resource-constrained settings. Lessons include the importance of balancing formal and informal institutions to ensure both political feasibility and enduring impact.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2025-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145781220","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abraraw Tadesse Ferede, Dagem Mekonen, Jacqueline E W Broerse, Ruth M H Peters, Negussie Deyessa, Dirk Essink
Gender-based violence (GBV) is a major public health issue, further intensified in humanitarian crises. In Ethiopia's northern conflict (2021-ongoing), the scale of GBV underscores the urgent need for context-sensitive policy and service delivery. We conducted a policy analysis of national GBV-related policies within the context of the Northern Ethiopia conflict. This was complemented by nine focus group discussions with relevant stakeholders; community representatives and ten key informant interviews with key policy makers at sub-national and national levels. Data were analyzed thematically using the Health Policy Triangle framework. No reviewed policies were contextualized for humanitarian emergencies or inclusive of all GBV forms. Most focused exclusively on sexual violence against women, overlooking other GBV types and male survivors. Policy development was largely top-down, involving government bodies and international actors, with minimal input from frontline providers or affected communities. There was also a lack of consensus on which policies are being implemented, driven by poor dissemination, resource constraints, limited prevalence data, and weak coordination. Ethiopia lacks a government-led, humanitarian-specific GBV policy. This hinders a coordinated health response. Strengthening community participation in policy formulation, ensuring inclusive and context-relevant policy content, improving coordination among all governmental and non governmental GBV actors, and addressing funding gaps are critical for effective GBV response in humanitarian settings.
{"title":"Gender-Based Violence Policies and Practices in Humanitarian Settings: A Qualitative Policy Analysis, North Ethiopia.","authors":"Abraraw Tadesse Ferede, Dagem Mekonen, Jacqueline E W Broerse, Ruth M H Peters, Negussie Deyessa, Dirk Essink","doi":"10.1093/heapol/czaf112","DOIUrl":"https://doi.org/10.1093/heapol/czaf112","url":null,"abstract":"<p><p>Gender-based violence (GBV) is a major public health issue, further intensified in humanitarian crises. In Ethiopia's northern conflict (2021-ongoing), the scale of GBV underscores the urgent need for context-sensitive policy and service delivery. We conducted a policy analysis of national GBV-related policies within the context of the Northern Ethiopia conflict. This was complemented by nine focus group discussions with relevant stakeholders; community representatives and ten key informant interviews with key policy makers at sub-national and national levels. Data were analyzed thematically using the Health Policy Triangle framework. No reviewed policies were contextualized for humanitarian emergencies or inclusive of all GBV forms. Most focused exclusively on sexual violence against women, overlooking other GBV types and male survivors. Policy development was largely top-down, involving government bodies and international actors, with minimal input from frontline providers or affected communities. There was also a lack of consensus on which policies are being implemented, driven by poor dissemination, resource constraints, limited prevalence data, and weak coordination. Ethiopia lacks a government-led, humanitarian-specific GBV policy. This hinders a coordinated health response. Strengthening community participation in policy formulation, ensuring inclusive and context-relevant policy content, improving coordination among all governmental and non governmental GBV actors, and addressing funding gaps are critical for effective GBV response in humanitarian settings.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2025-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145774417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Delaram Akhavein, Lea Elora A Conda, Sary Valenzuela, Percival Ethan Lao, Meru Sheel, Seye Abimbola, Geminn Louis C Apostol
As global framings of health continue to expand their reach, the Philippines, like many other countries, must navigate the overlapping pressures of donors, international institutions, and domestic political agendas in setting priorities. One such framing is the framing of health as a security issue. This study examines how health security framing - how it is interpreted and operationalised - influences priority-setting in the Philippines. Drawing on 25 interviews with government (at national and sub-national levels) and non-government actors, and using a realist approach, this study sought to identify the outcomes of health security framing (as triggered or reinforced by mechanisms such as uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) and the context in which the outcomes manifest. Findings show that health security framing reshapes priorities by reinforcing centralized, top-down approaches at both international and national levels. These framings influence not only what is prioritised, but also which actors make decisions and how those decisions are justified. At the implementation level, it manifests in health workers facing misaligned operational frameworks, vertical programming, and burdensome reporting requirements tied to donor funding. Security norms become institutionalized with the involvement of military and security actors in health. The study demonstrates that health security is not a static concept, but a dynamic phenomenon co-constructed through global discourses, donor agendas, and domestic governance practices, all of which are shaped by power relations and history. While health security mobilizes resources and political attention, it also introduces trade-offs that risk exacerbating inequities and diverting attention from the structural determinants of health.
{"title":"Governing health through security in the Philippines: a realist analysis.","authors":"Delaram Akhavein, Lea Elora A Conda, Sary Valenzuela, Percival Ethan Lao, Meru Sheel, Seye Abimbola, Geminn Louis C Apostol","doi":"10.1093/heapol/czaf110","DOIUrl":"https://doi.org/10.1093/heapol/czaf110","url":null,"abstract":"<p><p>As global framings of health continue to expand their reach, the Philippines, like many other countries, must navigate the overlapping pressures of donors, international institutions, and domestic political agendas in setting priorities. One such framing is the framing of health as a security issue. This study examines how health security framing - how it is interpreted and operationalised - influences priority-setting in the Philippines. Drawing on 25 interviews with government (at national and sub-national levels) and non-government actors, and using a realist approach, this study sought to identify the outcomes of health security framing (as triggered or reinforced by mechanisms such as uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) and the context in which the outcomes manifest. Findings show that health security framing reshapes priorities by reinforcing centralized, top-down approaches at both international and national levels. These framings influence not only what is prioritised, but also which actors make decisions and how those decisions are justified. At the implementation level, it manifests in health workers facing misaligned operational frameworks, vertical programming, and burdensome reporting requirements tied to donor funding. Security norms become institutionalized with the involvement of military and security actors in health. The study demonstrates that health security is not a static concept, but a dynamic phenomenon co-constructed through global discourses, donor agendas, and domestic governance practices, all of which are shaped by power relations and history. While health security mobilizes resources and political attention, it also introduces trade-offs that risk exacerbating inequities and diverting attention from the structural determinants of health.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2025-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145742493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The global health landscape is undergoing a significant transformation as traditional frameworks of cooperation face fragmentation amid geopolitical tensions. Declining support from Western nations, exemplified by US withdrawal from the WHO and cuts to programmes like PEPFAR, has exposed the profound instability of an aid architecture built on colonial dependencies. The COVID-19 pandemic, marked by vaccine nationalism, was a stark litmus test of this systemic failure for low- and middle-income countries (LMICs). This commentary argues that the current geopolitical fragmentation, while a crisis, also presents a critical opportunity to dismantle colonial legacies and reimagine global health equity not as a donor-driven ideal, but as a practice of shared power and sovereignty. We first document the rise of alternative pathways, critically examining China's health diplomacy and India's pharmaceutical disruption, while highlighting robust, LMIC-led initiatives like the African Medicines Agency and local mRNA vaccine production in Rwanda and Thailand. In response to the fractured status quo, we then propose a new global health compact built on four interdependent pillars: 1) Epistemic Justice, valuing local knowledge systems; 2) Structural Audacity in Financing, such as taxing multinational corporations for reparative funding; 3) Governance for Agency, ceding decisive power to LMICs; and 4) Open Knowledge and Innovation, by dismantling restrictive intellectual property regimes. Achieving this decolonized future requires concrete action from all stakeholders. We conclude with a blueprint urging high-income countries to cede power, LMICs to invest in local capacity, funders to provide untied financing, and researchers to practice equitable collaboration. This actionable agenda is the foundation for a truly equitable global health system capable of achieving Universal Health Coverage.
{"title":"Decolonising Global Health in an Age of Fragmentation: Reimagining Equity for Universal Health Coverage.","authors":"Emmanuel Kwasi Afriyie, Ridley Nsioge Mbwoge, Munawar Harun Koray","doi":"10.1093/heapol/czaf109","DOIUrl":"https://doi.org/10.1093/heapol/czaf109","url":null,"abstract":"<p><p>The global health landscape is undergoing a significant transformation as traditional frameworks of cooperation face fragmentation amid geopolitical tensions. Declining support from Western nations, exemplified by US withdrawal from the WHO and cuts to programmes like PEPFAR, has exposed the profound instability of an aid architecture built on colonial dependencies. The COVID-19 pandemic, marked by vaccine nationalism, was a stark litmus test of this systemic failure for low- and middle-income countries (LMICs). This commentary argues that the current geopolitical fragmentation, while a crisis, also presents a critical opportunity to dismantle colonial legacies and reimagine global health equity not as a donor-driven ideal, but as a practice of shared power and sovereignty. We first document the rise of alternative pathways, critically examining China's health diplomacy and India's pharmaceutical disruption, while highlighting robust, LMIC-led initiatives like the African Medicines Agency and local mRNA vaccine production in Rwanda and Thailand. In response to the fractured status quo, we then propose a new global health compact built on four interdependent pillars: 1) Epistemic Justice, valuing local knowledge systems; 2) Structural Audacity in Financing, such as taxing multinational corporations for reparative funding; 3) Governance for Agency, ceding decisive power to LMICs; and 4) Open Knowledge and Innovation, by dismantling restrictive intellectual property regimes. Achieving this decolonized future requires concrete action from all stakeholders. We conclude with a blueprint urging high-income countries to cede power, LMICs to invest in local capacity, funders to provide untied financing, and researchers to practice equitable collaboration. This actionable agenda is the foundation for a truly equitable global health system capable of achieving Universal Health Coverage.</p>","PeriodicalId":12926,"journal":{"name":"Health policy and planning","volume":" ","pages":""},"PeriodicalIF":3.1,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145722183","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}